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About this guide We have prepared this guide to help you to:
• learn about atrial fibrillation
• manage atrial fibrillation and reduce the risk of stroke
• find out about medicines and other treatment options for atrial fibrillation
This guide was prepared by: Jennifer Cruz RN(EC), MN, NP-Adult
Kamran Ahmad MD FRCPC
Paul Angaran MD FRCPC Paul Dorian MD FRCPC Victoria Korley MD FRCPC Iqwal Mangat MD, FRCPC Arnold Pinter MD
Contact Information:
Atrial Fibrillation Centre
St. Michael’s Hospital 7th Floor Donnelly Wing – Heart Health Unit 30 Bond Street Toronto, Ontario M5B 1W8 Telephone: (416) 864- 6060 ext. 3177 Fax: (416) 864- 5348
Visit our website: www.stmikesEP.com
Table of Contents
What makes a normal heart beat? @@@@@@@@@@@@@@@@..@@@...3
What is Atrial Fibrillation (AF)? @@@@@@@@@@@@@@@@@@@@[email protected]
What causes AF? @@@@@@@@@@@@@@@@@@@@@@@@@..@@6
What are common symptoms of AF? ......................................................................7
What are types of AF? @@@@@@@@@@@@@@@@@@@...@@@.@@..7
How is AF diagnosed? @@@@@@@@@@@@@@@@@@@...@@@@[email protected]
How is AF treated? @@@@@@@@@@@@.@@............................................10
What are the different types of treatment?.............................................................11 Medicines .@@.@@@.@@@@@@@@@@@........................................12
Electrical Cardioversion @@@@@@@@@@@@@@@@@@..@@.@12 Catheter Ablation@@.@@@@@@@@@@@@@@@@@@@@..@@12 Blood thinners (Anticoagulation) @@@@@@@@@@@@@@..@@@..13
Healthy Lifestyle Choices @@@@@@@@@@@@@@@@@@@@...@@@14
Follow-up @@@@@@@@@@@@@@@@@@@...@@@@@@@[email protected]
Useful Websites @@@@@@@@@@@@@...@@@@@@@@...@@@@....16
St. Michael’s Hospital. All rights reserved. This information is not intended as a
substitute for professional medical care. Ask your healthcare provider about this
information if you have any questions.
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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What makes a normal heart beat?
The heart is a large muscle with four chambers. There are two top chambers (left and
right) called the atria and two bottom chambers (left and right) called the ventricles. The
right-sided chambers collect “used” blood and then pump the blood to the lungs. In the
lungs, blood gets oxygen. The left sided chambers receive oxygen rich or “fresh” blood
from the lungs. Then they pump the blood out to the rest of the body (tissues, organs,
muscles, etc.).
The heart muscle contracts (or pumps) because of signals it gets from your body’s
natural pacemaker. The body’s natural pacemaker is called the sinoatrial node (SA
node). The brain and the SA node work with each other to tell the heart how fast to beat.
For example, it beats slower when resting and faster during exercise.
A regular heart beat makes the sound “lub-dub”. The SA node sends electrical signals
to the upper chambers. When electrical signals from the SA node reach the upper
chambers, the upper chambers beat (“lub”). Signals make their way to the lower
chambers via the atrioventricular node (AV node). This causes the lower chambers to
beat (“dub”).
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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What is Atrial Fibrillation (AF)?
Atrial fibrillation (AF) is a common rhythm problem of the upper chambers of the heart
(atria). This rhythm problem may cause the lower chambers of the heart (ventricles) to
move faster and in an irregular way. The picture below shows the difference between a
normal heart rhythm and an AF rhythm.
AF patients have fast and disorganized electrical activity which causes abnormal heart
beats. The atria “fibrillate” or quiver much faster than usual. They also beat much faster
than the ventricles:
Normal resting heart (beats per minute)
Patients with AF (beats per minute)
Atria 50-100 350 to 500
Ventricles 50-100 80 to 200
This irregular heartbeat may reduce how well the heart pumps blood to the body. This
happens because the ventricles may not have enough time to fill properly between beats.
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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During AF, the upper chambers of the heart do not fully contract in the normal way. This
increases the risk that blood clots may form. If a blood clot forms, it could break free and
travel through a blood vessel to the brain. A blood clot in the brain can cause a stroke.
It can block the flow of blood to part of the brain.
What are common signs of a stroke?
• weakness
• trouble speaking
• vision problems
• headache
• dizziness
If you have any of these signs,
go to the emergency department right away or call 9-1-1
What is Atrial flutter?
Atrial flutter is a condition related to AF, but the rhythm is more organized. Atrial flutter
usually causes a rapid, regular heart rhythm. During atrial flutter, the upper chambers or
atria contract at a very fast rate (250 to 300 beats per minute), and the lower chambers
or ventricles contract at 75-150 beats per minute.
It is possible that patients can have both AF and atrial flutter. But, this is rare. When a
person has both of these heart rhythms, one may be causing the other. For example,
atrial flutter may be causing AF.
Some of the information in this booklet on treatment of AF also applies to atrial flutter.
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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What causes AF?
AF is the most common type of heart rhythm problem (arrhythmia). More than 350,000
Canadians have AF. About 1 out of every 25 Canadians over the age of 65 has AF. But,
people under age 65 can have AF as well. The risk of getting AF increases with age.
About 1 out of every 10 people over the age of 80 lives with AF. Some people develop
AF without any known cause and without heart disease. This is called ‘lone AF’.
The root cause of AF is heart disease or another condition that leads to changes in the
upper chambers and electrical changes in the heart.
Certain factors may bring on an episode of AF, but do not directly cause AF. These
factors, also called triggers, are still being studied. An example of a trigger may be too
much caffeine or a stressful event. If you know your triggers, you should try to avoid
them. This can improve your symptoms during AF. If you are not bothered by your
symptoms during AF, then there is no need to avoid potential triggers of AF.
Your risk of getting AF is higher if you have:
• High blood pressure (hypertension)
• Coronary heart disease
• Valvular heart disease
• Thyroid disease
• Lung disease
• Recent open-heart surgery
• another type of heart rhythm problem
• an abnormal heart structure
The risk is also higher if you:
• Are over 60 years old
• Have sleep apnea
• Drink too much alcohol (More than 2 drinks per day)
• Are obese
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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What are common symptoms of AF?
Many people live with AF. If your AF is managed well with treatment, you can live a
normal life. AF does not cause a heart attack or sudden cardiac death. Some
people feel fine during AF, but others may have one or more symptoms of:
• Feeling of a rapid heart rate or feeling of “skipped” heart beats
• Problems breathing (shortness of breath)
• Dizziness or feeling faint
• Feeling tired or not able to do daily activities
• Chest pain, tightness or pressure
What are types of AF?
1. Paroxysmal AF – these are episodes of AF that come and go. The AF usually stops
on its own within 48 hours. Depending on the symptoms, these episodes can be
reduced with treatment.
2. Persistent AF – these are episodes that last longer than 7 days and do not stop on
their own. Usually, treatment is needed to help the heart return to a normal rhythm
3. Permanent AF – this type of AF is chronic. Chronic means that the AF will usually
last longer than 1 year. With chronic or permanent AF it may be hard to restore the
heart back to a normal rhythm. Sometimes it is not possible to try to stop the AF
episode altogether.
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How is AF diagnosed?
Your healthcare team will look over your health history, do a physical exam and some
tests. The results of the tests will show if you have AF.
• An electrocardiogram (ECG) records your heart beat and confirms if you have AF.
Other tests that you may need
• A Holter monitor is a special device that monitors your
heart rhythm. You might be asked to wear the Holter for
24 to 48 hours.
• Event recorder is like a Holter monitor but is worn for 2 weeks. This device records
the heart rhythm when you press the button during symptoms.
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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While not all tests may apply to you, other useful tests that can help in treatment of AF
are:
• Echocardiogram (echo - ultrasound) creates a
video picture of the heart beating, using sound. The
picture shows the size and function of the heart
chambers, heart valves and blood flow.
• Blood tests show how well the thyroid, kidney and liver are functioning. Blood test for
electrolytes and hemoglobin levels may also be done. These test results can show
factors that play a part in getting AF episodes. There may be things we can do to
change these factors.
• Chest x-ray to see basic heart and lung structures.
• Nuclear stress test to tell if the blood flow to the heart muscle is normal.
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• Heart CT (or CAT) Scan is used to see the heart
chambers and vessels of the heart.
• Electrophysiology study (EPS) to tell if you have other heart
rhythm problems. EPS shows the exact area of the rhythm
problem. Long wires called catheters are
inserted and guided into the heart. These
catheters transmit signals to tell the area of
the heart rhythm problem.
• Sleep Study to tell if you have sleep apnea, a sleeping disorder. Your sleep will be
monitored with special machines in the clinic or lab. Then, you will see a sleep
specialist to discuss the results of the sleep study.
How is AF treated?
Treatment for AF is different from patient to patient. The most common goals of AF
treatment are:
• to improve your symptoms
• to reduce your risk of stroke
The treatment depends on your symptoms and how AF is affecting you. It is important to
keep your heart beating at a normal rate. If your heart rate is too fast and is not treated
for a long time, the heart muscle can become weak.
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There are two main types of treatment:
• treatment to slow down the heart rate (rate control)
• treatment to help the heart keep a regular rhythm (rhythm control)
Rate control medicines slow down the heart rate during AF. They do not stop AF from
happening. This helps some people feel better and more able to do their usual activities.
Some patients may also need treatment with rhythm control. This can be a medicine
or a procedure to help your heart return to a normal rhythm.
What are the different types of treatment?
There are many ways to treat AF. Treatment is different for every patient. Your
symptoms during AF and the results of your tests will help show which choice of
treatment is best for you.
1. Medicines you take every day
Some patients may need to take both rate control medicines and rhythm control
medicines. Other patients only need one kind of medicine.
Rate control medicines are used to help control the heart rate. There are different
types of these medicines:
• beta blockers, such as metoprolol and bisoprolol.
• calcium channel blockers, such as diltiazem and tiazac.
• cardiac glycoside, such as digoxin.
Rhythm control medicines (Anti-arrhythmic drugs) are used to restore or keep a
normal heart rhythm.
• Examples of rhythm control medicines are: disopyramide, flecainaide,
propafenone, dronedarone, sotalol, and amiodarone.
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2. Medicines you take when you need them (also called Pill-in-the-Pocket)
This choice is only for patients who have AF once in a while (for example once every few
months). During AF symptoms, both rhythm control and rate control medicines can be
taken together.
• Taking these medicines during AF episodes can help bring your heart beat back to
normal.
• You may go to the Emergency Department less as you are able to better control
your abnormal heart beats.
• If “Pill-in-the-Pocket” works for you, you may not need to take pills every day for
AF. You may still need to take blood thinners.
3. Electrical Cardioversion
If AF does not stop with medicines, an electrical shock (or cardioversion) may be given.
• You will get medicine (sedation) that will keep
you relaxed during the cardioversion.
• A machine called a defibrillator will send a brief
electrical shock between two electrical pads
placed on your chest and back. The electrical
shock helps restore your heart to a normal
rhythm.
• After the electrical shock, you may get rhythm
control medicines. These medicines will help
your heart stay in normal rhythm and prevent AF.
4. Catheter Ablation
You may need this if the other treatments do not work, or they cause too many side
effects. This procedure puts long wires (catheters) through the veins in your groin or
neck. The wires are guided into the heart using an X-ray.
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• The catheters are used to burn certain heart cells that are causing the AF. This is
called ablation. If you need catheter ablation therapy, your healthcare team will
tell you more about it.
5. Blood thinners
Since AF increases your risk for stroke, almost everyone with AF needs blood thinners.
This is also called anticoagulation. The exact type of “blood thinner” depends on your
risk factors for stroke. The risk factors for stroke are:
� heart failure (congestive heart failure)
� high blood pressure (hypertension)
� age over 75 years
� diabetes
� prior stroke or stroke warning (transient ischemic attack or TIA).
Other risk factors may also be considered, such as: a history of vascular disease, age
over 65 years and being female.
Some patients only need to take aspirin everyday to reduce the risk of stroke. Others
require a stronger blood thinner such as warfarin (coumadin). Patients taking warfarin
need the dose changed based on the results of a blood test called INR (International
Normalized Ratio). Other available blood thinners are: dabigatran (pradaxa),
rivaroxaban (xarelto) and apixaban (eliquis). These blood thinners do not need blood
testing.
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Patients going for a cardioversion or ablation therapy need to be on blood thinners
before and after the procedure. A strong blood thinner is taken for about 1 month before
and 1 to 3 months after the procedure. The need for blood thinning lifelong after a
cardioversion or an ablation is determined by the individual stroke risks.
Choosing the most appropriate blood thinner is based on individual patient needs.
Speak with your healthcare team to find out which blood thinner is right for you.
Healthy Lifestyle Choices
1. Check your blood pressure regularly
High blood pressure can increase your risk for AF. See your family doctor regularly to
check your blood pressure. High blood pressure (hypertension) is often controlled by diet,
healthy lifestyle changes (like exercise) and medicines. Check your blood pressure
regularly to help your healthcare team know how to treat you.
2. Stop smoking
Smoking increases your risk for heart disease. If you are thinking about stopping, ask
your heath care team for help. There are programs to help you stop smoking, such as
including nicotine replacement therapy.
3. Eat well
Choose foods that are low in fat. The daily amount of fat in what you eat should be no
more than 65 grams for women and 90 grams for men. A low fat diet helps lower blood
cholesterol levels. Your doctor may also ask you to take drugs that lower cholesterol.
Use Canada’s Food Guide to Healthy Eating to help you plan healthy meals.
Some tips for healthy eating are:
• Eat more whole grains, fruits and vegetables
• Use very little salt (If your blood pressure is high, you may need to stop
eating foods with salt).
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If you are taking Warfarin (Coumadin), you will have to be careful about taking foods that
are high in vitamin K. Foods that are high in Vitamin K include green leafy vegetables.
Warfarin gets in the way of how vitamin K works in your body. Also, if you change the
amount of food you eat that is high in Vitamin K, this can change the amount of Warfarin
that you need. Ask your healthcare team which types of foods are high in Vitamin K, and
how to keep the amount you eat steady.
4. Exercise regularly
Exercise helps you lose weight, control cholesterol, reduce blood pressure and reduce
stress. Exercise is also good for the health of your heart, even if you have AF. If you
take drugs for AF, your heart rate may not increase as much during exercise. This
means that the drugs are doing a good job of slowing your heart rate. Your exercise
routine should really depend on how you feel. Exercise is good for your health, but do
not over do it. A good tip is to listen to your body.
5. Take caution with certain medicines
Some over-the-counter drugs such as nasal sprays, cold and herbal pills may make AF
worse. Ask your healthcare team before taking them.
Follow-up
If your AF is monitored and treated regularly, the risks and symptoms can be reduced.
The treatment can change over time and may depend on how you feel during AF. The
key is for you and your healthcare teams to use the treatment that works best for you.
St. Michael’s Hospital: Cardiac Arrhythmia Service. All rights reserved. September 2013
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Useful Websites:
Afib Innovation Program
www.afibinnovationprogram.com
American Heart Association Patient Information
www.americanheart.org/presenter.jhtml?identifier=4451
Heart and Stoke Foundation
www.heartandstroke.com/site/c.ikIQLcMWJtE/b.5052135/k.2C86/Heart_disease_
_Atrial_fibrillation.htm
Heart Rhythm Society Patient Information
www.hrsonline.org/PatientInfo/HeartRhythmDisorders/AFib/index.cfm
“Up to Date” Patient Information
www.uptodate.com/patients/content/topic.do?topicKey=~Q66zKoLyIHUj1&selecte
dTitle=1~150&source=search_result
WedMD Patient Education Centre
www.webmd.com/heart-disease/atrial-fibrillation/atrial-fibrillation-overview